Faculty Bibliography

BACKGROUND:Complicated grief (CG) is characterized by persistent, impairing grief after losing a loved one. Little is known about sleep disturbance in CG. Baseline prevalence of subjective sleep disturbance, impact of treatment on sleep, and impact of mid-treatment sleep on CG and quality of life outcomes were examined in adults with CG in secondary analyses of a clinical trial. METHODS:Patients with CG (n = 395, mean age =53.0; 78% female) were randomized to CGT+placebo, CGT+citalopram (CIT), CIT, or placebo. Subjective sleep disturbance was assessed by a grief-anchored sleep item (Pittsburgh Sleep Quality Index: PSQI-1) and a four-item sleep subscale of the Quick Inventory of Depressive Symptomatology (QIDS-4). Sleep disturbance was quantified as at least one QIDS-4 item with severity ≥2 or grief-related sleep disturbance ≥3 days a week for PSQI-1. Outcomes included the Inventory of Complicated Grief (ICG), Work and Social Adjustment Scale (WSAS), and Clinical Global Impressions Scale. RESULTS:Baseline sleep disturbance prevalence was 91% on the QIDS-4 and 46% for the grief-anchored PSQI-1. Baseline CG severity was significantly associated with sleep disturbance (QIDS-4: p = .015; PSQI-1: p = .001) after controlling for comorbid depression and PTSD. Sleep improved with treatment; those receiving CGT+CIT versus CIT evidenced better endpoint sleep (p = .027). Mid-treatment QIDS-4 significantly predicted improvement on outcome measures (all p < .01), though only WSAS remained significant after adjustment for mid-treatment ICG (p = .02). CONCLUSIONS:Greater CG severity is associated with poorer sleep beyond PTSD and depression comorbidity. Additional research including objective sleep measurement is needed to optimally elucidate and address sleep impairment associated with CG.

BACKGROUND:Prolonged grief disorder (PGD) is a new diagnosis in the 11th edition of the International Classification of Diseases, estimated to affect 1 in 10 bereaved people and causing significant distress and impairment. Maladaptive thoughts play an important role in PGD. We have previously validated the typical beliefs questionnaire (TBQ), which contains five kinds of thinking commonly seen in PGD: protesting the death, negative thoughts about the world, needing the person, less grief is wrong, and grieving too much. The current paper examines the role of maladaptive cognition as measured by the TBQ in PGD and its change with treatment. METHODS:Among participants in a multisite clinical trial including 394 adults, we examined (a) the relationship between maladaptive thoughts at baseline and treatment outcomes, (b) the relationship between maladaptive thoughts and suicidality at baseline and posttreatment, and (c) the effect of treatment with and without complicated grief therapy (CGT) on maladaptive thinking. RESULTS:TBQ scores were associated with treatment outcomes and were strongly related to suicidal thinking before and after treatment. TBQ scores showed significantly greater reduction in participants who received CGT with citalopram versus citalopram alone (adjusted mean standard error [SE] difference, -2.45 [0.85]; p = .004) and those who received CGT with placebo versus placebo alone (adjusted mean [SE] difference, -3.44 [0.90]; p < .001). CONCLUSIONS:Maladaptive thoughts, as measured by the TBQ, have clinical and research significance for PGD and its treatment.

BACKGROUND:Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS:To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. RESULTS:CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). CONCLUSIONS:Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.

Although mindfulness-based interventions (MBIs) have garnered empirical support for a wide range of psychological conditions, the psychological processes that mediate the relationship between MBIs and subsequent symptomatic improvement are less well-understood. In the present study we sought to examine, for the first time, the relationship between mindfulness, negative interpretation bias as measured by the homophone task, and anxiety among adults with Generalized Anxiety Disorder (GAD). Forty-two individuals with GAD completed measures of mindfulness, interpretation bias, and anxiety before and after treatment with Mindfulness-based Stress Reduction (MBSR). Contrary to prior research, we did not find evidence of an indirect relationship between baseline levels of mindfulness and anxiety via negative interpretation bias. MBSR did result in significant reductions in negative interpretation bias from baseline to post-treatment; however, we did not find evidence of an indirect relationship between changes in mindfulness and changes in anxiety via changes in interpretation bias. Taken together, these results provide minimal support for the hypothesized relationship between mindfulness, negative interpretation bias, and anxiety among adults with GAD. Limitations and specific suggestions for further inquiry are discussed.

Background: Complicated grief (CG) is hypothesized to include both attachment and traumatic distress symptoms, and a preliminary diagnosis has been placed in the trauma and stressor related DSM-5 category (APA, 2013). Posttraumatic stress disorder (PTSD) and CG often present comorbidly, and both result from a major stressor (Simon et al., 2007; Marques et al., 2013; Lenferink et al., 2018). Preliminary data suggest posttraumatic stress symptoms (PTSS) may be present across patients with CG, and not vary by whether the loss is violent or accidental in nature such as required for PTSD diagnoses (Simon et al., 2013; Kersting et al., 2011). Much less is known about how PTSS changes with CG targeted treatment, whether this change is impacted by the nature of the death, or whether it may be necessary to target PTSS separately from grief to improve functional outcomes.
Method(s): Participants were 395 individuals (mean age +/- SD = 53.0 +/- 14.5 years; 78.0% women) with a primary diagnosis of CG based on structured clinical interviews and an Inventory of Complicated Grief (ICG) score>=30. Data were derived from the previously published 20-week multi-center RCT of complicated grief therapy plus pill placebo (CGT + PLA), CGT plus citalopram (CGT + CIT), citalopram (CIT), or placebo (PLA) (Shear et al., 2016). DSM-IV PTSS were assessed using the 17-item self-report Davidson Trauma Scale (DTS). DTS total score of 40 was proposed by the developers of the scale as a cut-off for a diagnosis of PTSD, and has been frequently used as a threshold in previous studies (Davidson et al., 1997; Kastello et al., 2016; Khitab et al., 2013). Our primary analysis examined the adjusted mean difference from baseline in the DTS total and subscale scores (i.e., intrusion, avoidance-numbing, hyperarousal) over three follow-up periods (week 12, 16, and 20) by treatment arm using longitudinal mixed effects regression with participant specific random intercepts. In follow-up analyses, we investigated whether cause of death (violent vs. nonviolent) moderated the relationship between treatments and DTS total score by introducing interaction terms between cause of death and treatment arms in the mixed effects regression model.
Result(s): In the full sample, the mean DTS total score at baseline was 63.2 +/- 27.2, and 77.7% (n = 307) had DTS>=40. There was a general decreasing trend of mean DTS total scores over the 20-week period with a mean adjusted reduction of 27.4 points (d = 0.6) from baseline to week 12 (p < 0.001), and a reduction of 30.7 points (d = 0.7) from baseline to week 20 (p < 0.001). There was no significant difference in change in DTS total score at week 12 by treatment group. However, at weeks 16 and 20, CGT + PLA and CGT + CIT were each associated with a significant DTS reduction compared to placebo alone, while CIT was not. For CGT + PLA vs. PLA, there was 8.8 point (d = 0.14) greater reduction in DTS total score from baseline to week 16 (p = 0.01), and 12.5 point (d = 0.19) greater reduction from baseline to week 20 (p < 0.001). For CGT + CIT vs PLA, there was a 10.0 point (d = 0.15) greater reduction in adjusted DTS total score from baseline to week 16 (p < 0.001), and 10.7 point (d = 0.16) greater decrease from baseline to week 20 (p < 0.001). Similar trends were observed for DTS subscales-CGT + PLA and CGT + CIT demonstrated consistent reduction compared to PLA. In the model with interaction terms between treatments and cause of death, the decrease in DTS score for CGT + CIT compared to PLA was 9.5 points (d = 0.12) greater for those who had violent death compared to those who did not experience violent death (p = 0.04). For CGT + CIT vs CGT + PLA, however, the reduction in DTS total score was 4.2 points (d = 0.04) greater in those who experienced violent death compared to those who did not, but the difference was not statistically significant (p = 0.53).
Conclusion(s): Adults with primary CG assigned to CGT with or without medication demonstrated a significantly larger reduction in PTSS compared to pill placebo, whereas citalopram alone did not. These data parallel findings from the primary study findings for grief (Shear et al., 2016), and demonstrate that CGT may be an effective intervention for PTSS in those with CG. A high level of PTSS were present in this primary CG sample, and PTSS were comparable at baseline for those with violent and non-violent losses. For those who lost someone to violent death, while these data found initial support for greater PTSS reduction for combination therapy with CGT and citalopram compared to placebo, we did not find evidence for a significant benefit of combined therapy over CGT alone for CG due to violent loss. More research is needed to fully understand the role of traumatic distress and its optimal treatment in CG

OBJECTIVE:Extensive research supports the use of prolonged exposure (PE) and cognitive processing therapy (CPT), for posttraumatic stress disorder (PTSD) in veterans and service members. PE and CPT have been disseminated nationally across the Department of Veterans Affairs (VA) facilities. Many service members and veterans receive care outside the VA where access to these gold standard psychotherapies can be limited. This paper presents a novel program developed to train community providers in the use of PE and CPT and their application to veterans with PTSD through the use of a medium-touch approach to consultation. METHOD/METHODS:Four 2-day trainings (2 in PE, 2 in CPT) were delivered to a total of 170 participants over an 8-month period. A subset of approximately 10 providers per training (n = 42) received 6 months of weekly, group phone consultation following the 2-day training. All providers were assessed pre- and posttraining, as well as 3 and 6 months after their training. Outcomes for the training workshop alone and the training plus 6 months of consultation were compared. RESULTS:While participant knowledge, t = -22.57, p < .001 and comfort (χ² = 74.00, p < .001) with PE and CPT significantly increased immediately following the 2-day training, those who received consultation were more likely to implement (χ² = 20.88, p < .001) and either complete or be close to completing PE or CPT with patients (χ² = 20.57, p < .001) 6 months following training. CONCLUSIONS:Despite some limitations, these preliminary data support that consultation is an important component to include in PTSD therapy training and implementation in the community. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The current study examined Veterans' attitudes about the potential use of telepsychiatry for mental health treatment in routine clinical settings. Data were collected from Veteran outpatients (N = 253) who completed a series of self-report screening measures as part of their initial evaluation at an outpatient clinic providing care to Veterans with deployment-related mental health problems. Using a de-identified data repository, symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and stress, as well as attitudes and level of comfort with receiving treatment through telehealth were assessed. Overall interest in telepsychiatry was mixed, with 25.7% of patients being "not at all comfortable" and 13.4% being "extremely comfortable" using telepsychiatry from home. Approximately one third (32.8%) of participants indicated a clear preference for telepsychiatry compared to in-person mental health visits. There were no differences in telepsychiatry preferences by symptom severity, demographic variables, rural versus urban location, or endorsed barriers to care. Although telepsychiatry may be a viable means of increasing access, patient preference should be considered, as a substantial percentage of Veterans in this study preferred in-person visits. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 38-43.].

BACKGROUND AND OBJECTIVES/OBJECTIVE:Anxiety disorders are characterized by biased perceptual judgment. An experimental model using simple verbal instruction to target specific decision parameters that influence perceptual judgment was developed to test if it could influence anger perception, and to examine differences between individuals with social anxiety disorder (SAD) relative to generalized anxiety disorder (GAD) or non-psychiatric controls. METHODS:Anger perception was decomposed into three decision parameters (perceptual similarity of angry vs. not-angry facial expressions, base rate of encountering angry vs. not-angry expressions, payoff for correct vs. incorrect categorization of face stimuli) using a signal detection framework. Participants with SAD (n = 97), GAD (n = 90), and controls (n = 98) were assigned an instruction condition emphasizing one of the three decision parameters. Anger perception pre-vs. post-instruction and its interaction with diagnosis were examined. RESULTS:For all participants, base rate instructions impacted response bias over and above practice effects, supporting the validity of this instructional task-based approach to altering response bias. We failed to find a similarity or payoff instruction effect, nor a diagnosis interaction. LIMITATIONS/CONCLUSIONS:Future instructional tasks may need to more closely target core cognitive and perceptual biases in anxiety disorders to identify specific deficits and how to optimally influence them. CONCLUSIONS:This study demonstrates that specific decision parameters underlying perceptual judgment can be experimentally manipulated. Although our study failed to show diagnosis specific effects, it suggests that individual parameter "estimation" deficits may be experimentally isolated and potentially targeted, with the ultimate goal of developing an objective approach to personalized intervention targeting biased perceptual judgments in anxiety disorders.